Norfolk Island Ditching: Still Many Questions

If you talk to someone who's been involved in a serious aircraft accident long enough, they'll eventually get around to two things: The accident constantly intrudes in the daily thought process and any external description of it—an official accident report or news reports—won't ring quite true. Experiencing something so traumatic isn't the same as reading someone reporting it.

I thought of that when I interviewed Dominic James over the weekend. James was the Captain on that Westwind that ditched off Norfolk Island on November 18, 2009. At the time, I blogged that the accident report on this one is going to be interesting. Now that the report is complete, I got what I wished for. It's interesting alright, but for the wrong reasons. This accident appears to be a classic example of the linked chain, but the ATSB's report simply ignores many of the links, speeding apace to its conclusion: The crew was responsible.

And so it was. The flight crew—James and First Officer Zoe Cupit—had the final vote and sole ability to sunder the accident chain. They failed to do that, but the report itself fails to explain that in some ways, the company, the system and CASA set James up for an accident and left him to his command authority to avoid it. When a perfectly competent pilot throws away a perfectly good airplane, it's often the result of a mindset patterned by past success and both external and internal pressures. This accident seemed to have all of that. As we reported in today's news, James is challenging the ATSB report and an Australian Senate hearing on it is planned for early next month. He says he's not ducking fault or responsibility, but believes the report simply doesn't give an accurate picture of all the factors involved in the accident.

To refresh, the flight was a Westwind medevac mission with a stable patient from Apia, Samoa to Melbourne, Australia. To save you the trouble of hauling out your atlas, that's some 2800-nautical miles, almost all of it over water. It's the distance from New York to Los Angeles, plus another 700 miles. Norfolk Island was the planned fuel stop, a distance of 1600 miles. James said the Westwind had the legs for trips like this, but only if everything went to plan.

For James and Cupit, it didn't. With good VFR forecast for Norfolk, neither the company's policy nor Australian regulation required a named alternate, so none was contemplated. In any event, it's doubtful that one could have been reached. The closest was Noumea in New Caledonia, 400 miles north of Norfolk Island. The Westwind departed with 83 percent of full fuel; mains full, tips empty. Even with the tip fuel, Noumea was unlikely, given the fuel required for climb. When the weather tanked at Norfolk, the crew had no option other than to land there. It couldn't and ditching was the only survivable option other than a desperation, homemade, below-minimums approach. The airplane simply lacked the capability to do the trip with contingency fuel.

The number of links in this accident chain not covered in the ATSB report are too numerous to cover here. But as James explains it, they're obvious to him in retrospect. In hindsight, it is clear how this chain of events led him to the decisions he made. On a previous trip, James had been told Norfolk's automated weather reports were notoriously pessimistic and forecasts for the island were iffy. Other similar aircraft routinely made such trips with no drama, despite Norfolk's exceptional remoteness. Pel-Air seemed to have a loose relationship with regulatory adherence and CASA failed to oversee the company aggressively, as evidenced by an internal report only recently made public. ATSB never mentioned this report.

Pel-Air airplanes routinely operated in or through RVSM airspace, but the Westwind wasn't RVSM equipped, according to James. Controllers would give the flight a bye on RVSM if they could climb to FL390, which the Westwind could do only if light, thus the decision to leave tip fuel behind. Noumea was potentially a paper alternate, but James said the local authorities there didn't want Pel-Air airplanes arriving because they lacked TCAS II and GPWS, not to mention RVSM. The accident airplane had just had TCAS and GPWS installed, but James and Cupit had never seen it and hadn't been trained in its use.

The ATSB made a great deal of discussing James' fuel planning, especially the oceanic technique that routinely requires points of no return and/or critical points, which are continuation decision thresholds when few or no alternates are available. The ATSB conceded that based on the forecast, an alternate wasn't required and that the crew had enough fuel for a flight that proceeded normally, but no contingency for a de-pressurization event that would force the airplane to lower, less fuel-efficient altitudes. If the drift down happens in the wrong place, the range can dwindle to the point of neither being able to return to the departure nor reach an alternate. James insists his fuel load covered this and when he asked the ATSB for its fuel calcs, they declined the request. He had the data reviewed independently to confirm his calculations.

Even with the good forecast, James got an updated METAR for Norfolk from Fiji ATC. The controller misstated the ceiling as 6000 feet rather than 600 feet. A later corrected METAR relayed via HF was garbled in poor atmospherics at dusk. James couldn't explain why he didn't receive it, but he knows he didn't. Fiji refused to release the audio tape of the transmission. "There's no way you sit on your hands for an hour after getting a METAR like that," James said. "You'd have to be a suicidal maniac."

That missed METAR may have been the final or most critical link in the accident chain. Once the Westwind passed Fiji, it was committed to Norfolk, save for a brief diversionary window to Noumea. I like to think if I'd been in that cockpit, I'd have surely had the threat and error management thing going on and would have diverted sooner, just as any competent pilot should. Maybe you think the same thing. The reality is that given the circumstances, I can imagine myself being sucked down the same dark hole James and Cupit found themselves in. For me, personally, that's a creepy truth, but a truth nonetheless.

Later in the week, I'll take a look at another accident that is eerily similar to this one. It occurred 42 years ago in the Caribbean.

Hindsight is 20/20 vision would you really divert knowing that you have a 6000ft base at the destination. The fact that it was only 600ft was unknown until arrival and then it's too late. One pilot when he had to land due to no power landed in the Hudson. HERO! One pilot had to land due to no fuel put into the sea VILLAIN?

How many people died? Methinks James and Cupit deserve some credit for the lack of injuries.

It's worth following the link in the AvWeb report to the 4Corners investigation, with further links to informative stories and blogs on the issue.

There are still a few holes in the story.

Most importantly, what has the FO to say? She was there alongside Dominic James throughout the event, yet there's no comment from her, neither in Paul's article here nor in the 4Corners program. Does she endorse James' narrative, or not?

Then why did the ATSB refuse to share its fuel calculations? No douibt a bureaucratic excuse was given, but the only real reason must be fear of mistakes being discovered.

Similarly, why did Fiji ATC refuse to release the recording of its METAR relay? Again, whatever excuse was given, there can be only one real reason.

One aspect of this I didn't discuss with Dom James was the idea of using an improvised approach. The VOR 29--presumably a GPS overlay--has best mins of 484 feet HAA. So slow the airplane up as much as possible, establish the approach and descend to MDA. A mile from the threshold, give up the obstacle clearance and hope the controlling obstacle isn't on the centerline. Descend to 200 feet HAA and continue the pass. If the runway appears soon enough, land. If appears too late, retract the wheels and land on the belly. You'd stop shorter. (Runway is 6300 feet.)

But then you have to measure that against the risk of a night ditching in heavy seas. Obviously, the ditching was the right choice, but ahead of the game, I have no idea how to evaluate the risks of the two choices and I'm glad I didn't have to.

I think the crew made the very best out of a bad situation. We should all do as well.

Paul, having been involved in a major aircraft accident myself, although not aboard the aircraft thankfully, your first paragraph is so true. I have never heard anyone describe it like that but you are spot on. My support is completely with Dominic and Zoe in this case.

Sorry, but what do you mean about ATC 'turning a blind eye' or 'giving a bye' to non-RVSM equipped aircraft, operating in RVSM airspace?

I can't specifically speak for other FIRs, but in Australia (where the accident aircraft was registered), there is nothing to stop non-RVSM aircraft operating in RVSM airspace. The only difference is different vertical separation standards apply (2000ft vs 1000ft).

It would not be the first time that regulatory elements contributing to an accident are not part of the post accident investigation as well as the investigation methods themselves considered part of the overall conclusion. Air New Zealand FLT 901 crashed on the side of Mt Erebus, Antartica on Nov 28, 1977 (CFIT in VMC conditions!) killing all 257 people. Questions regarding flight plan accuracy and errors, flight ops in arctic regions, crash investigation techniques and Airline attempts at covering up evidence, depicted in a Royal Commission finding as being a "Litany of Lies" by QC Justice Mahon added much unfortunate drama to what was already a devistating tragedy. Check out Wikipedia on FLT 901 for a summary of a nightmare of politics, bureachracy and chain of events leading up to this tragic accident. Only through the resolute persistence by a number of people was the full understanding of the chain of events finally identified including a greater understanding of “sector white out” that contributed to the set of events that resulted in this accident.Only then was flight safety truly improved.

Nice article. This guy was being painted as a bit of a big headed hot shot over here. He was in the running for some "Bachelor of the year" thing and after the crash photos were published of him in his uniform with his shirt open. To be honest, I was buying that line until now, especially after the ATSB preliminary report. Now I'm not so sure.

On the idea of the improvised approach - I agree with every thing Paul said. He ditched competently and got everyone out of a sinking jet, including the heavily pregnant patient.

Good coverage Paul. Like John Hogan, due to press coverage, I also thought at the time Dominc James was culpable and careless.

As an Australian, I am now appalled by our ATSB report on the Pel-Air ditching. It is a sloppy report. It took the ABC-TV 4-Corners interview for the ATSB head to agree to check facts and later agree the last weather report passed to crew just before descent was not 600 feet cloud base as contained in the report (later corrected) but 6000 feet. Had Dominic been told the correct cloud base of 600 feet, he may still have not descended and possibly successfully diverted to Noumea.

Compare this report to the 23 Sept 1991 QF1 B747 overrun at Bangkok. Despite that captain overriding the PF FO's decision made well down the runway, to go around, the ATSB absolved the crew. They ascribed the accident to a long chain of events relating to QF's change of procedure in using carbon braking with flaps 25, rather than flaps 30 with reverse thrust. That report set a standard on insightful recognition of the swiss cheese, and careful evaluation of the whole chain of events. Unlike Dominic, the QF crew continued to fly without rebuke. That report made us all appreciative of a fair informed and insightful ATSB.

Not this report. Its total dump on Dominic, despite glaring deficiencies in Pel-Air's operation, and the many factors going against the crew, is a shameful.

--- previous post ---
You also don't mention the fatigue factor. Dominic got only a few hours sleep on turnaround after flying out to Apia, due a delayed checkin to the hotel, and sleep disturbance. Fatigue must have been evident. He was unable to get internet access to obtain weather/Notams and had to use a dodgy mobile phone. He had ZERO operational support from Pel-Air, an aircraft that was all but banned from flying into Noumea where he had flown once previously and was detained and warned by French authorities for operating a non-compliant aircraft in French Airspace. Not inconsequential factors.

In short, he had so many red flags stacking up against him, its a credit that he managed as he did. He could have grounded himself, but the patient may have been further impaired. Was there significant pressure on him to return a suffering patient to hospital in Australia without delay? His management was either incompetent or knowingly deficient, in continually requiring crew to operate challenging sectors without appropriate risk assessments being made, or ameliorations provided for, or providing operational decision support.

Dominic is gracious in accepting his deficiencies in not having broken the chain of events, but he had many factors stacked against him. He deserved to come out of this flawed ATSB report in a much better light.

Paul, I do agree with you on two points. The FO has not publicly been visible in any aspect of the report or the publicity. We simply don't know her role as FO in questioning or supporting command decisions or in assisting a fatigued pressured captain.

It also occurred to me that a makeshift GPS approach overlaid on the NDB approach to lower minimums may have been a better alternative. Not sure which was the braver decision, busting minimums or the water ditching. Neither was a better bet, and both were likely to result in lost lives.

The only thing you can say to this is that Dominc's aircraft handling of the ditching made it possible for all to survive. Though the lack of alerting to the Norfolk operator of approximate ditching location nearly cost all their lives. Surely that should have been an FO function?

Finally, there have been pilot comments on the ATSB's inaccurate statements about fuel calculations and requirements for single engine or depressurised calculations.

Dominic was not without fault, but he has been nailed to a cross of an operator of failed management, a regulator of failed oversight, inadequate equipment, and an unfairly biased if not incompetent ATSB.

Evidently, CASA left FO Cupit alone and concentrated on James for enforcement action. She now works for a major carrier, which declined to have her interviewed for the 4Corners report.

As to fatigue, I asked James about this. He said he can't say if the long duty day was a factor, but added that it didn't help. The Noumea issue wasn't addressed in the ATSB report, but I think it was a bigger factor in decisionmaking than might be apparent from just reading about the accident.

I got an e-mail from a Norfolk Islander who said he watched and heard the event unfold in real time. He lives near the airport and could see the airplane pass over. He couldn't understand why they didn't try an approach to 4, which he thought was clearer at the time. He also commented on the lack of communications with Unicom. I'm not sure why this was so and James wasn't either. But I suspect it's due to the natural tunnel vision that sets in for people in extremis.

As for the cobbled up approach, that's a tough one. From the comfort and safety of my cup-holder-equipped blogging chair, it's easy to speculate on this.

When GPS moving maps first appeared, I trained these techniques with IFR students. They require a bit of mental math on fly, which is hard to do under duress, and they also require a degree of faith that obstacles don't loom on the centerline because you are intentionally throwing away the obstacle clearance that a properly designed approach provides.

I know from my own research that a daylight ditching in a piston single or twin is a high survival percentage event--like 90 percent. If the water's not cold, it would be the safer choice against the homebrew approach, in my estimation.

But a jet, at night in moderate seas? There's no experience to suggest outcomes. Night ditchings in general are lower survival. But there are hardly enough of them to make a useful assessment.

Don't forget, this was an IFR ditching. He did not see the sea surface at any time during the touchdown and flared using radar altimeter data. So there was no chance to set up parallel to the swell or consider wind or wave.

One other note: Consistent reports in large aircraft ditching reveal that the occupants in the back of the aircraft will experience the hardest impact. That was true here, where the flight nurse was seriously injured and true in the USAirways Hudson ditching, too.

Thanks Paul for researching this further. This is a very complex risk analysis case.
I agree with Peter Pain's assessment of the missing factors within this investigation. The Risk Factors not explored by the investigation include: Inadequate to nil availablity to communications to flight planning and weather while in Apia, Samoa. : No available crew assistance by operator, Pel-Air. : Pel-Air's lack of crew and management standardization for remote, complex flights. : The inability and nor willingness for ATC to provide continued weather updates during the flight, and the errant information when provided.

From a Risk Analysis perspective, these are the "Contributing Safety Factors" that were the responsibility of ATC and operator, the Systemic Risk Factors that the pilot experienced during this event. I don't see how more regulatory guidance can help the pilot when there were so many communication failures leading to a single outcome. If you believe the investigation document in total. The pilot was responsible for every aspect of the flight and the system the pilot worked within was responsible for nothing. Nonsense.

A couple of thoughts regarding the selection of an airport, especially an airport with no hopes for reaching an alternate.
Call it the yellow stripe down my back, but once I was faced with running low on fuel and landing a jet at an airport with a single usable runway at night.
I chose to land for fuel at the alternate because of two reasons:
If another aircraft so much as blew a tire upon landing ahead of us, and was disabled on the runway, I would have needed to make an off airport landing.
If the runway lights were inoperative for whatever reason, resorting to landing with car lights pointed down the runway was not my idea of fun.
Just my two cents.
Jim

@JimKraft
Good comment Jim, however a couple of points worth considering in this case:

1. Pel Air has had prior "events" that always made me wonder about their operational management. I think their crews regard them as only a stepping stone to the airlines or a decent job. Hence, not a lot of mentoring going on. (Supposition and observation from long ago, I do not know this for a fact today).
2. Pel Air is not a high margin operation. I am sure Dominic would have felt some compunction to operate "economically". For him, Noumea was a no-go because of his prior detainment and the aircraft's continued non compliance for French Airspace. New Zealand is a costly alternative diversion, and may also have put the crew out of duty time. Why do that with a good weather report? Fiji was his only possibility other than fly direct to Norfolk. Again, why stop at Fiji given the good weather report. After all, other Pel Air flights had done this before, and he had comfortably flown the route the night before.

Not saying he should not have made a different decision. With hindsight, Dominic is likely to be a safer pilot today.
Given his environment at the time, I understand why he did what he did.
What he needed was a JimKraft back at PelAir counselling him by phone on his flight plan before he departed. That would have made the world of difference in this case.

When I was still a student pilot aged 20, I nearly ditched a Grunau Baby, although with quite adverse circumstances to my credit -- nonetheless, years later I recalled a moment of triumph when I felt having passed the point of no return: I was unconsciously thrilled at the thought of becoming a hero if I got to land that lame duck onto that tiny playground at the lake shore... I neither ditched nor entirely crashed the bird, but I wasn't injured -- and I definitely renounced piloting!

Having left the scene through the stage door, I promised myself to once come back through the main entrance -- and see there... 20 years later I invented a revolutionary rotary-wing concept!

I also remember Paninternational's BAC 1-11 crash-landing on a motorway shortly after take-off from Hamburg (D), with the captain and his female copilot among the survivors -- whereby the operator denied the official findings of an engines failure... similarly, the fact that in our case FO Zoe Cupit was completely left out of the investigation looks somehow intriguing to me.

Striving for heroism being a well known stance among pilots, and considering that it happened 11 months after the almost too perfect Hudson ditching (which, BTW, might have been staged to positively overwrite 9/11...), the presence of a female FO may have mesmerized a pilot who "was being painted as a bit of a big headed hot shot over here", as John Hogan reports...